Foreign body (FB) in the tracheobronchial tree is not uncommon, especially in infants and children. They often present with respiratory obstruction, which can lead to death if not removed in time. Despite public awareness and education, FB aspiration continues to be a problem among patients. We report a case of tracheobronchial FB in a 13-year-old boy who had accidentally aspirated a sharp metallic needle, used during root canal treatment by a dental surgeon. The FB was removed successfully without any complication. FB inhalation is possible while conducting a surgical procedure in the oral cavity. This situation is a life-threatening condition, affecting the patient, and may also create a legal issue to the concerned caregivers. Every clinician should be aware of this type of mishappening during oral cavity procedure.

Accidental inhalation of foreign body (FB) in the airway is a common emergency in the otolaryngology practice. Accidental inhalation of FBs to the airway continues to be a cause of morbidity and mortality and needs prompt identification and early treatment of the potentially serious and sometimes fatal outcome. Although inhaled FBs are common in infant and children, they can occur at any age. Patients who undergo oral cavity or oropharyngeal procedures, have oral appliances or poor dentition, become intoxicated, receive sedatives, have neurological or psychiatric diseases, or are mentally challenged are at high risk of inhalation of FB into the airway.[1] In airway FB, the most common symptoms and findings are cough, dyspnea, decreased breath sounds, radiopaque FB, air trapping, and atelectasis.[2] Delayed diagnosis of FB may mimic conditions, such as asthma, croup, pneumonia, and gastroesophageal reflux.[3] There are various types of FBs that have been reported in the air passage – organic and inorganic, metallic and nonmetallic. A sharp needle-like material used during root canal treatment (RCT) accidentally entering the airway is an extremely rare FB of the tracheobronchial tree. Here, we report a tracheobronchial FB in a 13-year-old boy who had accidentally aspirated a sharp metallic needle, during RCT. The aim of this report is to present an unusual FB in tracheobronchial tree to create awareness among caregivers performing procedures in the oral cavity or oropharynx in awake state.

Case Report

A 13-year-old boy was referred by a dentist to the outpatient department of otorhinolaryngology for sudden onset of cough and dyspnea with complaints of aspiration of FB. There was a history of accidental inhalation of a sharp needle of 2 cm length (ProTaper SX hand file used for orifice opening) during RCT. On clinical examination, the patient had mild breathlessness and coughing. On auscultation, there was minimally reduced air entry into the left lungs. On examination, nose, ear, oral cavity, oropharynx, and neck were within normal limit. X-ray of the neck and chest done outside showed a radiopaque sharp FB at the left bronchus near the carina [Figure 1]. Computed tomography (CT) scan of the neck and chest confirmed the position of the needle [Figure 2]. Since the patient had mild dyspnea, bronchodilators were administered and he was taken to the operation theater for rigid bronchoscopy under general anesthesia.

The patient was already in empty stomach for 4 h before the rigid bronchoscopy. Premedication of injection glycopyrrolate 10 mg/kg intravenous (IV), injection midazolam 0.04 mg/kg IV, and injection fentanyl 1 mg/kg IV and preoxygenation for 3 min were given. Dexamethasone (0.1 mg/kg) was also given. The patient was immobilized with the use of hypnotic dose of propofol (2 mg/kg) with maintaining infusion of 100–300 mg/kg for titrating the depth anesthesia. The usual laryngoscopy was done, and 1% lidocaine was sprayed larynx and trachea. Then, it was then changed to rigid bronchoscopy. The FB [Figure 3] was successfully removed by rigid ventilating bronchoscope and optical forceps from the left bronchus without any complications. The patient was given antibiotics and nebulization with bronchodilators. The boy was discharged after 48 h.

Chevalier Jackson stated that the sole cause of inhalation of sharp FB in the tracheobronchial tree is carelessness on part of the persons in putting pins in the mouth or children imitating the bad example of their elders.[4] This is still true nowadays. Undiagnosed airway FBs may result in asphyxia, pneumonia, bronchiectasis, atelectasis, and even death. The severity of airway FB depends on the age of the patient, site of lodgment, size, composition of the FB, and duration, for which it has been lodged. Most of the FB inhalation occurs in children between 1 and 3 years of age. This is because (1) they do not have molars, necessary for grinding of food, (2) they have less controlled and coordinated swallowing and immaturity in laryngeal elevation and glottis closure, (3) there have tendency to explore the environment by placing the objects in mouth, and (4) they often run and play at the time of ingestion.[5] There are variety of FBs reported in the laryngotracheal airway. Food or food products are majority among all FBs, and reported incidence is as high as 70% of all FBs.[6] Unusual types of FB, such as broken tracheostomy tube, leech, broomstick, and bubble gums, have also been reported. A sharp needle inhaled into the airway during RCT is extremely rare and creates a dangerous situation. A child with a history of sudden-onset cough and wheeze, especially in the absence of any known pulmonary diseases such as bronchial asthma or chronic pulmonary infection, should be suspected of having an airway FB.[7] The important issue in airway FB is accurate diagnosis and speedy removal. History-taking and clinical examination can provide diagnostic clues, but a doubtful history of FB inhalation may delay the diagnosis.[8] Sometimes, FB inhalation may escape the diagnosis, particularly if there is no recollection of the episode. Hence, it is necessary to screen and X-ray every patient who is coming to the outpatient department with a history of swallowed FB presenting with sudden cough or dyspnea.[9] In case of inhaled FB in the airway, X-ray chest shows significant findings such as atelectasis or air trapping. Even though chest X-ray is generally the first imaging modality used for the diagnosis, it may yield negative results up to 30% of children who aspirate FBs as most are nonradiopaque.[7] Since, in our case, the patient had come immediately after aspiration of the FB, no significant changes in chest X-ray were seen except FB in the left bronchus near the carina. Negative imaging studies, however, do not exclude the presence of FB in the airway. Definitive diagnosis is often made by rigid bronchoscopy, but this is an invasive procedure, which needs anesthesia.[10] Alternate to bronchoscopic evaluation, the patient with suspected airway FB is evaluated with CT scan. CT scan is strengthened by the use of multislice CT scan with realistic three-dimensional reconstruction and virtual bronchoscopy.[11] If a FB is inhaled into the laryngotracheal airways, it can be removed with the help of rigid or flexible bronchoscope. Rigid bronchoscopy is an important technique, permitting removal of the tracheobronchial FBs.[12] Early identification and removal of FB are always better for the successful outcome. After FB lodgment, there are pathological changes like local inflammation, edema, and granulation tissue formation occur which may lead to further airway obstruction and making difficulty in bronchoscopic identification and removal of of foreign body.[13] During RCT, optimum alertness should be kept in mind so that it will prevent this type of life-threatening situation. Prevention is the most important element in reducing morbidity. As prevention is the key behind FB inhalation, more efforts should be given to educate caregivers and patients. Small spherical-shaped food items such as seeds and nuts may cause airway obstruction and asphyxia. In pediatric group, all these types of food should be avoided until the child is able to chew them adequately while sitting.

Conclusion

FB aspiration is a preventable mishap. A high index of suspicion, careful history-taking, meticulous clinical examination, and neck and chest radiograph are essential for early diagnosis of airway FB. Aspiration of a sharp needle during RCT is a rare but potentially lethal condition. Care and alertness during dental procedure help to prevent slippage of the FB into the airway.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.